Pope Benedict XVI said in his press conference on the plane to Cameroon that condom distributions aren’t the answer to AIDS in Africa. That response could even increase the problem, he said. The words ignited an international firestorm.
The New York Times said the Pope “deserves no credence when he distorts scientific findings about the value of condoms.” The Seattle Times decried “Pope Benedict’s alternative universe.”
But what Benedict actually said was much deeper and more nuanced than generally reported.
Asked about the Church’s approach to fighting AIDS in Africa, Benedict replied, in part: “I would say that this problem of AIDS can’t be overcome only with publicity slogans. If there is not the soul, if the Africans are not helped, the scourge can’t be resolved with the distribution of condoms: On the contrary, there is a risk of increasing the problem.”
For 25 years, an intensely polarized global debate over condoms has focused on what’s right — or wrong — with that thin piece of latex.
But when the Holy Father speaks of “publicity slogans” and “distribution,” he’s not talking just about a piece of latex. He’s talking about marketing.
Is he correct? Does condom marketing risk increasing the problem?
“Yes,” replies medical anthropologist Edward Green, director of the AIDS Prevention Research Project at Harvard University. “Marketing slogans — which promote condoms as sexy and exciting — can encourage people to have riskier sex and actually increase their risk for AIDS.”
A classic example of this backfire phenomenon — known as “risk compensation” — occurred in a study in Uganda. Young men given condoms and told how to use them had more sex partners, thereby putting themselves at higher HIV risk than men who received no condom education.
After 25 years of condom promotion, Green explained, “scientists have no good evidence that condoms will reduce HIV infection rates and AIDS deaths in general-population epidemics like those in sub-Saharan Africa.”
He added, “The scientific theory devised in the 1980s that condom marketing would solve Africa’s AIDS tragedy hasn’t panned out.”
More Condoms = More AIDS?
The good news is that a fresh, new scientific AIDS-prevention paradigm for Africa has emerged: “Not all AIDS epidemics are alike,” Green said. “We now know there are different kinds of epidemics — with different solutions.”
Yes, Green said, condom promotions have lowered HIV rates in some small concentrated epidemics, such as those among homosexuals in San Francisco and prostitutes in Bangkok. But they haven’t worked in Africa’s big epidemics.
“The mainstream HIV/AIDS community has continued to champion condom use as critical in all types of HIV epidemics, despite the evidence that condoms don’t work in general-population epidemics like those in Africa,” explained Green. He has published hundreds of articles and one book, Rethinking AIDS Prevention, to explain this new paradigm.
A UNAIDS-commissioned 2004 review examined the evidence to see how effective condom promotions had been in the fight against AIDS in sub-Saharan Africa — and found no evidence condom marketing had lowered HIV rates.
“On the contrary, increased condom sales actually went hand-in-hand with higher HIV rates,” said lead researcher Norman Hearst, professor of family medicine and epidemiology at the University of California, San Francisco.
In Botswana, condom sales rose from 1 million in 1993 to 3 million in 2001. Meanwhile, HIV prevalence among urban pregnant women skyrocketed from 27% to 45%. In Cameroon, as condom sales increased from 6 million to 15 million a year, HIV prevalence tripled from 3% to 9%.
One problem with condom promotions in Africa, Hearst said, is that no more than 5% of any given population use condoms consistently with their regular partners. And in Africa, it’s those regular partners who drive the pandemic.
In light of the latest evidence, many former condom advocates are leaping off the condom-promotion bandwagon. In a 2006 Lancet article “Confessions of a Condom Lover,” James Shelton, a scientist with the United States Agency for International Development, observed that although his “devotion to condoms spans three decades” and he’s helped provide billions of them, it’s hard to see any effect from condoms in Africa’s population-wide epidemics.
On the contrary, in South Africa, “public programs provided 346 million condoms,” and 69% of single people ages 15 to 24 had used a condom the last time they had sex, Shelton wrote. ”Yet infection continues apparently unabated.”
Five years ago in The Lancet, 150 of the world’s leading AIDS researchers and HIV experts signed a “common ground” statement, calling for condoms to be promoted as a first-line defense only in small, concentrated epidemics like those among commercial sex workers. The answer to Africa’s population-wide epidemics, the experts agreed, was fidelity for married couples and abstinence for youth.
In the March issue of Studies in Family Planning, scientists again sounded the trumpet for a “fresh approach” to AIDS prevention. The standard global “prevention toolbox,” based on condom promotion, HIV testing and treating sexually-transmitted diseases like herpes, has “failed utterly” in sub-Saharan Africa, they said.
In short, beneath the public outcry greeting Benedict’s statements about condom marketing, a paradigm shift has occurred in AIDS-prevention science. And this new paradigm strongly supports what the Pope said.
Still, old paradigms die hard, and not everyone is convinced.
Said Canadian AIDS activist Stephen Lewis, “Every stitch of scientific evidence says condoms are the best preventive measure we have against the virus.”
What does Lewis think about all the new-paradigm evidence cited above?
When asked, he quoted many other people around the world who had also criticized the Pope — from the World Health Organization, which repeated the old-paradigm dogma that “condoms are highly effective to prevent transmission of HIV if they are used correctly and consistently,” to the German Green Party European deputy, who called the Pope’s comments “close to premeditated murder.”
But where is the scientific evidence to back up these old-paradigm opinions when it comes to African AIDS?
Green said, “In fact, it doesn’t exist.”
Invisible Sexual Networks
About one-half of 1% of the world’s population has HIV/AIDS. Yet in one Swaziland study, 42.6% of pregnant women tested HIV-positive.
New-paradigm scientists say the answer lies buried in sub-Saharan Africa’s cultural sexual patterns.
Populations in most of the world are monogamous, or at least serially monogamous (one partner after another), explains anthropologist Green. In the U.S. and Europe, people usually break up with one lover before taking up with another.
But in Africa, many men and women have long-term sexual relationships with two or more regular partners.
In Botswana, with one of the world’s highest HIV rates, 43% of men and 17% of women surveyed had two or more regular sex partners. In Malawi, 65% of the villagers on one small island were connected in one huge sexual network.
Articles in leading journals, from Science and British Medical Journal to The Lancet, show it’s these invisible interconnected webs of relationships that sustain sub-Saharan Africa’s population-wide AIDS pandemic.
Green explained, “These ongoing sex partnerships become interlocked until they resemble a giant, invisible web of relationships through which the AIDS virus silently spreads.”
When Africans break up these invisible networks — by promoting faithful monogamy — HIV rates fall.
After Uganda launched its famous ABC (Abstain, Be Faithful, or use a Condom) campaign — with “B” as the pillar — fidelity to one sex partner rose from 59% to 79% among men and from 77% to 91% among women. Meanwhile, the proportion of men having three or more sex partners dropped from 15% to 3%.
As promiscuous sex declined, Uganda’s HIV rates plunged — from 15% in the early 1990s to about 4% in 2003.
Other African nations report similar victories. When the proportion of Kenyans remaining faithful rose from 70% to 83% of men and from 96% to 98% of women, HIV prevalence fell from 10% to 7%. Likewise, when married men became more faithful in Zimbabwe, HIV prevalence among pregnant women plunged from 32% to 24%.
“In every country worldwide in which HIV has declined, there have been increases in levels of faithfulness and usually abstinence, as well,” Green and Allison Herling Ruark wrote last year in First Things.
On the plane to Cameroon, Benedict spoke of a deeper reality about African AIDS than that captured by publicity slogans, headlines and sound bytes. In addition to his comments about condoms, the Pope also said, “The solution can only be found in a double commitment: first, a humanization of sexuality, that is, a spiritual and human renewal that brings with it a new way of behaving with each other; and second, a true friendship, also and above all for those who suffer, the willingness — even with sacrifice and self-denial — to be with the suffering.” In short, he called for a conversion of heart by the unfaithful and forgiveness and mercy for AIDS sufferers. He was talking about love.
When The Seattle Times wrote of “Pope Benedict’s alternative universe,” the editors got one thing right. Benedict indeed lives in an “alternative universe” — the universe of higher truth — that most newspapers miss.
Award-winning investigative medical reporter
Sue Ellin Browder has been to Uganda and
has written about HIV/AIDS prevention in
Africa since 2006.